Download Nutrition and Myofascial Pain Management

Ian A. Cyrus, MS, R.Ac., Dipl.Ac., OBT, CH
Practitioner
Acupuncture & Oriental Medicine as Physical Medicine
An Integrative Approach
NUTRITION and MYOFASCIAL PAIN MANAGEMENT
Nutrition of special concern in patients with Myofascial Pain Syndromes are the
water-soluble vitamins B1, B6, B12, folic acid, vitamin C, and certain elements: calcium,
magnesium, iron, and potassium.
Nutritional deficiencies, especially those involving water-soluble vitamins, are
especially common when patients have poor dietary habits, drink excessive amounts of
alcohol, or have other chronic diseases. Nearly half of the patients who are treated for
chronic myofascial pain require resolution of vitamin inadequacies for lasting relief.
A Vitamin is a nutrient that plays an essential role in normal body metabolism as
a coenzyme to an apoenzyme. A coenzyme is a diffusible, heat-stable substance of low
molecular weight that, when combined with an inactive protein called apoenzyme, forms
an active compound or complete enzyme called holoenzyme.
A need for better vitamin nutrition appears at three levels: vitamin insufficiency,
deficiency, and dependence. A vitamin insufficiency requires the body to make some
degree of metabolic adjustment because the amount of the coenzyme (vitamin) is limited.
Myofascial pain syndromes are aggravated by insufficient levels of at least four Bcomplex vitamins as listed above. Vitamin deficiency, on the other hand, is a level of
serum (fluids that moistens the surfaces of serous membranes – the watery portion of the
blood after coagulation) vitamin, generally below the accepted lower normal range, that
is associated with overt clinical diseases such as pellagra or pernicious anemia. Vitamin
inadequacy has been known to increase the irritability of Myofascial Trigger Points
(MTrPs). Since an energy crisis is a key link in the chain chemical changes that are
characteristic of MTrPs, it is to be expected that anything that interferes with the energy
supply of muscles will aggravate MTrPs.
A vitamin deficiency may be established by laboratory evidence of abnormally
low serum and tissue values for a particular vitamin, by excretion of abnormal metabolic
products, by the therapeutic effect of vitamin supplementation, or by a combination of the
three.
Vitamin dependence is observed in only a few individuals who have a congenital
deficiency of an enzyme that requires vitamin as a coenzyme. This dependence may
require megadosage of the vitamin to compensate for the congenital lack of the enzyme
that requires that vitamin. The larger group of people that have a congenital insufficiency
of the enzyme have a congenital increased need for the corresponding vitamin.
As mentioned earlier, there are five vitamins of special importance to myofascial
pain syndromes. They are; B1, B6, B12, folic acid, and vitamin C. This does not in any
way imply that the others are unimportant for optimal health, only that, based on current
knowledge, they are less critical for the relief of MTrP symptoms.
Vitamin B1 (Thiamine Pyrophosphate):
Vitamin B1 is considered to be essential for normal energy production within the
cell, and may be a factor in the energy crisis that is a part of the pathophysiology of a
MTrP. Further, Vitamin B1 is essential for normal nerve function. This vitamin is also
known as the “morale vitamin” due to its beneficial effects on the nervous system and
mental attitude. Neuropathy can be a significant factor in the development of MTrP.
Vitamin B1 insufficiency can be detected by the presence of peripheral
neuropathy characterized by diminished distal pain and temperature perception in the legs
and feet, and by loss of vibration sense. Ankle tendon reflexes may also be lost, but not
necessarily so in mild sensory neuropathy. Some Vitamin B1 deficient patients have
nocturnal calf cramps, mild edema, constipation, fatigue, and decreased vibratory
perception in relation to nerve fiber length. When given Vitamin B1 parenterally, patients
may promptly lose several pounds by diuresis with resolution of edema, have softer
stools (the body is no longer removing moisture from the bowel to supply the edema),
and are relieved of nocturnal cramps.
The abuse of alcohol can lead to signs and symptoms that are a variable
composite of three diseases; alcoholism, Vitamin B1 deficiency, and liver dysfunction. In
addition to inadequate ingestion of Vitamin B1, a number of factors can increase the need
for this vitamin. Vitamin B1 absorption is impaired by alcohol ingestion, liver injury,
magesium deficiency, tanins (found in tea), and antacids. Therefore, tea, alkalinizers, and
alcohol should not be taken with food. Vitamin B1 is destroyed by thiaminase, which is
found in a variety of fish, and in bracken fern, which grows in upland pastures where it
can pose a hazard to foraging animals. Excretion (loss) of Thiamine is potentiated by
diuretics and probably drinking large amounts of water, which also causes diuresis.
Vitamin B1 is available over-the-counter in 10-, 50- and 100mg tablets. It is also
available for injection as Betalin Sc in 1 ml ampules and in 10 ml and 3o ml vials, at a
concentration of 100 mg/ml of thiamine. The therapeutic oral dose usually recommended
is 10 mg daily for several weeks, or until evidence of deficiency has disappeared.
Increasing this to 50 mg daily will cause no harm and will insure providing for patients
with an exceptional need for the vitamin. A B-50 supplement contains 50 mg of thiamine
and is an ample daily dose to protect nearly all individuals from thiamine insufficiency
and can be taken indefinitely as a safe, inexpensive form of health insurance.
Vitamin B6 (Pyridoxine):
Vitamin B6 is considered important in Myofascial Pain Syndromes (MPS)
because of its role in energy metabolism and in nerve function. Patients with chronic
myofascial pain are a select group who show a high prevalence of vitamin inadequacies.
Many of these patients do well on large doses of vitamin supplements. Vitamin B6
deficiency has been linked to Carpal Tunnel Syndrome. However, its use as a treatment
for this condition is controversial and inconclusive. It is also critical for the synthesis of
and/or metabolism of nearly all neurotransmitters, including norepinephrine and
serotonin, which strongly influences pain perception.
Vitamin B6 affects both physical and mental health. It is beneficial in treating
water retention, and is necessary for the production of hydrochloric acid and the
absorption of fats and protein. Vitamin B6 also aid in maintaining sodium and potassium
balance necessary for optimal muscle function. It is a required nutrient for the nervous
system, and is needed for normal brain function and for the synthesis of the nucleic acids
RNA and DNA, which contain the genetic instructions for normal cellular growth.
Vitamin B6 plays an important role in cancer immunity and aids in the prevention
of arteriosclerosis. It inhibits the formation of a toxic chemical called homocysteine,
which attacks the heart muscle and allows the deposition of cholesterol around the heart
muscle.
Vitamin B6 requirement rises roughly in proportion to the increase in protien
intake and with age. The National Research Council (Great Britain) RDA for vitamin B6
is 1.6 mg for adult females and 1.4 mg for adult males, whereas the 1989 National
Academy of Sciences (USA) RDA remain at the previous level of 1.4 mg for adult
females and 2.0 mg for adult males. The current RDA of 2.0 per day may be more than is
necessary to maintain the minimum health of a normal adult (with no exceptional needs).
Vitamin B6 is available over-the-counter in 10-, 25- and 50 mg tablets, and in larger
amounts by prescription. Parenteral pyridoxine hydrochloride is available in vials of 10
and 30 ml in a concentration of 100 mg/ml. A single intra-muscular injection of
pyridoxine effectively raises the serum level of the vitamin. Again, a B-50 vitamin
supplement contains 50 mg of pyridoxine and is an ample dose to protect nearly all
individuals from pyridoxine insufficiency. This vitamin can be taken indefinitely and is
relative inexpensive.
Vitamin B6 deficiency has been linked to excessive alcohol consumption, oral
contraceptives, and use of corticosteriods. The need for vitamin B6 is increased in
hyperthyroid and both dialyzed and undialyzed uremic patients. Also, the requirement for
vitamin B6 in pregnant and lactating women is markedly increased.
Vitamin B12 (Cobalamin) and Folic Acid:
Cobalamin and folic acid are considered together because their metabolism and
function are intimately linked. These two essential enzyme co-enzyme cofactors
(essential because they must be supplied by outside sources as they cannot be synthesized
by humans) are required DNA synthesis in erythropoiesis and in rapidly dividing cells
such as those in the gastrointestinal tract, and for fatty acid synthesis that is critical for
nerve myelin formation.
Role in Myofascial Pain Syndromes. Vitamin B12 and folic acid insufficiency
and deficiency states can be seen in chronic myofascial pain syndromes (MPS). An
explanation of why deficiency of these two vitamins would aggravate the painfulness of
myofascial trigger points (MTrPs) is not clear and needs further investigative inquiry.
Lack of vitamin B12 and folic acid reduces blood cell production. The blood cells
transport oxygen to the muscles, oxygen that is essential for their energy metabolism. A
severe local energy crisis exists in the region of the dysfunctional endplates of MTrPs.
The crisis releases substances substances which sensitize local pain receptors, causing
pain and local tenderness. It is now known that Vitamin B12 deficiency may be
associated with peripheral neuropathy. Neuropathy is associated with increased MTrP
irritability. However, the mechanism with respect to dysfunction in MPS is not clear.
Patients with acute lumbar or cervical radiculopathy can present with acute MPS
before there is any clinical sign of radiculopathy. In some cases of MPS can result from
nerve injury resulting, for example, from post lumbar-laminectomy. Metabloic nerve
dysfunction resulting injury can also lead to the formation or the persistence MTrP’s.
Functions of Vitamin B12. Vitamin B12 serves numerous essential metabolic
functions that includes but not limited to the following:
1.
2.
3.
4.
5.
6.
Deoxyribonucleic Acid (DNA) synthesis
Regeneration of intrinsic folates which is also critical to the syntheseis of
DNA
The transport of Folate to, and its storage in cells
Fat and Carbohydrate metabolism
Protein metabolism
Reduction of Sulf-hydryl groups
Since Vitamin B12 and Folic Acid are required for the synthesis of DNA, both are
necessary for normal growth and tissue repair. Deficiency of Folic Acid impairs the
synthesis of DNA causing megaloblastosis in all duplicating cells of the body. This is
most commonly seen in bone marrow cells.
Folic Acid is critical to the development of the brain and essential for its normal
functioning after birth. Insufficiency of Folic Acid is the most common vitamin
inadequacy and among those inadequacies like to perpetuate MTrps. It should be noted
that symptoms described by patients with myofascial pain who have marginally low
serum Folate levels are similar to, but less intense than, many symptoms reported by
patients with obvious neurologic disorders responsive to Folic Acid therapy Increased
susceptability to MTrPs are commonly observed in patients with low Folic Acid levels.
They tire easily, sleep poorly, and feel discouraged and depressed. These patients also
feel cold and have a reduced basal temperature, as do patients with thyroid hypofunction;
their symptoms are often relieved by multivitamin therapy including Folic Acid.
Deficiency of Vitamin B12 and Folic Acid should be identified in the management of
MTrPs.
Vitamin C (Ascorbic Acid):
This vitamin is of clinical importance to the muscles because it can prevent most
post-exercise soreness or stiffness; it also corrects the increase in capillary fragility
associated with ascorbic acid which significantly complicates MTrP needling.
Ascorbic acid is involved in a vast array of essential body functions, including
collagen synthesis, degradation of amino acids, and the synthesis of two
neurotransmitters (epinephrine and serotonin).
Collagen constitutes nearly one quarter of the protein in body tissues. The strong
reducing action of ascorbic acid is needed for hydroxylation of the amino acids lysine and
praline to form the protocollagen molecule. This function may be assisted by ascorbic
acid inhibition of hyaluronidase.
Ascorbic acid has been shown to be important in wound (pressure sores) healing,
bruising (capillary wall fragility), amino acid degradation, neurotransmitter synthesis,
stress response, toxic substance protection, scurvy, and immunity. According to Travell,
1982, ascorbic acid does influence the immune system, but its role is unclear. Travell
wrote that ascorbic acid helps to alleviate bouts of diarrhea due to food allergy, and to
decrease toxicity and MTrP activity caused by chronic infection.
The recommended dose of ascorbic acid is 60 mg/day which will prevent scurvy.
A physiological dose of as much as 500 mg/day ensures a normal metabolic pool of
ascorbic acid to meet emergency demands, or a mega dose of 2-8 g/day, which may have
nonscorbutic effects such as protection from colds and cancer. The daily dose necessary
to ensure steady-state saturation levels in the tissues is about 450 mg/day and is best
taken in two or three doses per day. Oral intake of beyond tissue saturation should not be
necessary, but the optimal intake required depends on highly variable stress factors.
When one is sick there is a greater tolerance for Vitamin C, than when one is in good
health. This suggests that megadoses are unnecessary when one is well, yet may be
therapeutic when in poor health.
Ascorbic acid can interact with other vitamins. It can interact with folic acid as it
is important in its absorption. Absorption of folic acid can increase with oral
administration of ascorbic acid in the presence of liver disease. Dose of more than 500
mg of ascorbic acid can lead to lower serum levels of Vitamin B-12. Ascorbic acid can
also lead to increased absorption of some metallic ions such as iron which may be
desirable and mercury which may undesirable. Ascorbic acid increases the amount of
warfarin (coumadin, a widely prescribed blood thinner) required to maintain the same
therapeutic effect on blood clotting, i.e. it lowers prothrombin time in patients on
warfarin. Large doses of ascorbic acid can cause loose stools that can often be misdiagnosed as spastic colon and a non-specific urethritis. The daily requirement of
ascorbic acid may increase 3 to 10 fold, requiring daily amounts of up 500 mg three times
per day. Cigarette smoking decreases serum levels of ascorbic acid substantially requiring
therapeutic supplementation.
Dietary Minerals and Trace Elements (Calcium, Magnesium, Potassium, Iron):
Several minerals, especially iron, calcium, potassium, and Magnesium, are needed for
normal muscle function. Clinical observations indicate that deficiency of the
aforementioned minerals tend to increase irritability of MTrP.
Iron is an essential component of the hemoglobin and myoglobin molecules, which
transport oxygen to and within the muscle fibers to meet energy demands. Another role
of iron is the regulation of hormonal functions like thyroid hormone that again plays a
critical role in energy metabolism and clinically important in chronic myofascial pain
syndromes. Finally, there is the role of iron in the body’s temperature regulation that may
affect body temperature and perception of coldness that is seen in persons with
myofascial pain.
Requirements:
Iron are determined by daily iron losses, which are about 0.8-1.0
mg daily, except in menstruating women whose losses are 1.4-2.4 mg/day. About 10% of
dietary is absorbed, with a ceiling of 4-5 mg/day in anemic individuals. Reduced iron
stores must be replenished in iron deficient persons, although iron supplements may be
difficult for some persons to take because gastric irritation, constipation, or diarrhea that
develops in almost half of those taking them.
Sources:
Dietary iron is present as easily absorbed heme iron or as poorly absorbed
nonheme iron. Nonheme iron absorption is enhanced by absorption promoters, the most
potent being ascorbic acid or vitamin C. Inhibitors of nonheme iron absorption include
phytates (Phytic acids ound in cereal grains, nuts, and legumes) and calcium. Calcium in
milk, cheese, or as a supplement can decrease nonheme iron absorption by 50% and can
also significantly reduce absorption of heme iron. Calcium supplements should not be
taken with iron supplements. Phytic acids chelate or leach heavy metals and are potent
inhibitors of iron absorption, but the presence of phytic acids in nuts and soy are offset by
the high iron content of these foods. The strong iron absorption promoter ascorbic acid
can overcome the effect of dietary inhibitors significantly.
Causes of Insufficiency and Deficiency:
1.
2.
3.
4.
5.
Menstruation
Possible carcinoma in men
Gastric irritation with microscopic blood loss in both men and women who
take NSAIDS (Non-Steroidal Anti-Inflammatory Drugs)
Pernicious Anemia
Moderate exercise has been shown to reduce iron stores as measured by serum
levels. Other the other hand, moderate exercise also increases iron absorption
Determining Iron Insufficiency and/or Deficiency:
Measure iron stores by the serum ferritin test. Levels of 20 ng/ml or less signify iron store
depletion. Levels of 30-50 ng/ml may indicate a need for replacement of iron stores.
Treatment of Iron Insufficiency and/or Deficiency:
Treat iron depletion at ferritin levels of 30 ng/ml or lower, even levels of up to 40 ng/ml
to prevent iron depletion.
150 mg of iron (equivalent of elemental iron) are taken twice daily if tolerated, or once
daily if necessitated due to constipation or gastric irritation. Iron can be taken with folic
acid (1 mg) to lessen the symptom of gastric irritation.
Iron supplements are not taken with calcium supplements or dairy products. However,
taking them with vitamin C helps absorption. Iron supplements are available with stool
softeners and in different formulations. Therefore, finding one that works for you is
possible.
Once serum ferritin levels reaches 30-40 ng/ml, a small dietary supplement of 12-15 mg,
commonly found in most multivitamin with mineral preparations is enough to maintain
tissue iron stores.
Warning:
Iron supplementation should “always” be monitored to avoid iron storage
and hemochromatosis. Checking serum level every three months are adequate to monitor
supplementation at higher doses, and every six months until stable for lower dose
maintenance. Iron supplements should be given unless iron insufficiency is established
through the measurement of serum ferritin levels because iron overload can lead to
hemochromatosis, eschemic heart disease and poorer outcome after stroke.
Calcium:
Optimum Calcium Intake:
Young Adults and adolescents:
Women (ages 25 – 50):
Women (postmenopausal not on Estrogen Replacement ):
Women (postmenopausal on Estrogen Replacement):
Adult males:
Over 65 (all persons):
1200 – 1500 mg/day
1000 mg/day
1000 mg/day
1500 mg/day
1000 mg/day
1500 mg/day
*Calcium intakes up to 2500 mg/day do not result in hypercalcemia in normal persons.
There are no studies to link abnormalities in calcium metabolism to myofascial pain
syndromes (MPS). However, there is an anecdotal link suggesting that disturbances in
serum calcium level is extremely uncommon in patient with MPS. However, calcium is
of great interest in MPS because of it’s role in muscle contraction and in modulating pain
responses.
Potassium:
Recommended daily allowance:
< (50 mEq)
• more is needed if there are unusual losses
Normal concentration of serum potassium:
3.5 – 5.0 mEq/L
Total body potassium is low in hypothyroidism and high in hyperthyroidism. Clinical
observations have shown that hypokalemia aggravates myofascial trigger points (MTrPs).
Potassium deficiency disturbs the function of smooth muscle (cardiac muscle) as
evidenced by electro-cardiogram.
Potassium rich foods:
Fruits (especially bananas and citrus fruits)
Potatoes
Green leafy vegetables
Wheat germ
Beans
Lentils
Nuts
Dates
Prunes
Dietary considerations:
In general, a healthy diet should be high in potassium and low in sodium. However, this
is not true for those with adrenal insufficiency.
A diet high in fat refined sugar, over-salted food, and low in potassium, can lead to
potassium deficiency. Diarrhea, laxatives, and certain diuretics increases potassium loss.
Magnesium:
Studies thus have failed to show a link between low magnesium and the perpetuation of
myofascial pain syndromes (MPS). However, there is some anecdotal evidence that
suggest that erythrocyte magnesium levels are significantly lower in patients with
myofascial pain.
Magnesium however, is critical to many cellular functions, including energy production,
protein formation, and cellular replication. Magnesium participates in more than 300
enzymatic reactions in the body, in particular those processes involved in energy
production, i.e., production of ATP (Adenosine Tri-Phosphate). Magnesium is also
required for the activation of the sodium-potassium pump that pumps sodium out of, and
potassium into the cells. Therefore, magnesium deficiency results in decreased
intracellular potassium. As a result of lower magnesium and potassium within the cell,
cell function is greatly disrupted.
Magnesium as been referred to as “nature’s calcium channel-blocker”
Future studies of magnesium with respect to MPS need to be conducted.
Recommended daily intake (RDI):
Adults:
4.5 mg/kg or about 250-350/day